CareSource Medicare CareSource Advantage®  (HMO SNP) Pharmacy Information

Before providing care or prescribing medicine for your patients, please review the CareSource Advantage (HMO SNP)  2012 Preferred Drug List, and the  2012 Preferred Drug List Changes. If a medication requires step therapy or prior authorization use the Pharmacy Coverage Determination form. For more information please call Provider Services at 1-800-488-0134.

Preferred Drug List (Formulary Medication)

The 2012 Preferred Drug List (Formulary) or the is the list of drugs that are covered as a pharmacy plan benefit for CareSource members. The CareSource Advantage formulary was selected in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. CareSource Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a CareSource Advantage network pharmacy, and other plan rules are followed.

Tiered Medications

The 2012 medications are categorized into four tiers: (Tier 1), generic drugs (Tier 2), preferred brand and generic drugs (Tier 3), non-preferred brand and non-preferred generic drugs and (Tier 4) specialty or biological brand and generic drugs.

Tiered Cost Sharing Exceptions

A member must meet appropriate medical necessity criteria before the tiered cost sharing exceptions will be approved. To determine medical necessity, the CareSource Advantage Plan will verify, through the provider’s supporting statement(s) and/or standards documented in clinical guidelines adopted by the Plan, that all drugs in the lower preferred tiers:

1) Would not be as effective for the member as the requested drug,
2) Would have adverse effects for the member, or both.

Tiered cost sharing exception requests will be processed through CareSource’s Pharmacy Benefit Manager’s (PBM) prior authorization review process.

Pharmacy Prior Authorization

CareSource will process coverage determinations and exception requests in accordance with Medicare Part D regulations. Requests will be handled through the Prior Authorization review process. Prior authorization requires a drug to be “pre-approved” in order for it to be covered under a benefit plan.

The Prior Authorization staff will adhere to the CareSource Advantage CMS approved criteria. The PBM’s National Pharmacy and Therapeutics Committee establishes clinical guidelines, and other professionally recognized standards in reviewing each case, rendering a decision based on established protocols and guidelines.

Providers can submit prior authorization requests by phone or fax. Providers will be required to submit pertinent medical/drug history, prior treatment history, and any other necessary supporting clinical information with the request. Standard requests will be reviewed and determinations will be made within 72 hours.

Expedited or urgent requests will be reviewed and determinations will be made in 24 hours. A request is considered urgent if the requestor believes that applying the standard process may seriously jeopardize the member’s life, health, or ability to regain maximum function. Providers will be notified by phone or fax of the determination.

Prescribers or their designated agents may request authorization by one of the following mechanisms:
• Toll-free phone number: 1-800-488-0134
• Written request via fax: 1-866-950-9375 for oral medications and injectable/specialty medications

Formulary Exceptions

The 2012 Preferred Drug List (Formulary) contains many commonly prescribed drugs. During the course of a plan member’s medical care, there may be instances when a member requires a non-formulary drug or a drug that has formulary limits or restrictions (e.g., step-therapy requirements, prior authorization, or quantity limits).

CareSource Advantage may approve an exception request for a non-formulary drug or a drug that has formulary limits or restrictions when medically necessary. To determine medical necessity, CareSource Advantage (HMO SNP) will verify through the provider’s supporting statement(s) and/or standards documented in clinical guidelines adopted by CareSource Advantage, that

  • The member has tried and failed and/or has documented contradictions or intolerance to the equivalent formulary medications, and
  • No other formulary agent is appropriate to treat the member’s condition.

Exception requests will be processed through CareSource Advantage’s Prior Authorization staff.

Pharmacy Management Program

CareSource uses a PBM (Pharmacy Benefit Manager) to handle prior authorization requests. All requests for pharmaceutical prior authorizations should be directed to CareSource: Medicare Prior authorizations by calling toll free 1-800-488-0134.

Please fax your completed Prior Authorization Form to CareSource at 1-866-950-9375. Click here to view a copy of the 2012 CareSource Advantage Preferred Drug List.

For technical requests, you can contact the pharmacy technical help desk at 1-888-527-0014.